A blog about nothing.

Thursday, March 31, 2016

DEATH AND DIAPERS


For a limited time Pampers are on sale. Stock up while supplies last. I'm kidding. That clip from Napoleon Dynamite is a riot, though. And don't go throwing away your Huggies just yet. Because the world is getting older, and adult-diaper sales are forecast to rise 50% in the next 5 years, outpacing baby nappies twentyfold. The leading brand for the elderly is actually called Depend, but Huggies sounds so cute. This is a serious issue and not to be wiped over carelessly. In 2050 in the U.S., the population aged 65 and over is projected to be over 80 million, almost double what it is today. So, a lot of Depends.

A recent debate sponsored by Intelligence Squared featured lifespans as its topic. The question: What if we didn’t have to grow old and die? The average American can now expect to live almost 80 years, largely due to improved sanitation and vaccinations before which people left the Earth a lot closer to aged 50. But even though they may be wearing Depends, most people want more. Researchers around the world are tirelessly trying to arrest aging through biotechnology and find a cure for age-related diseases like cancer and dementia.

Ask a person about the ethical and social consequences of radically increasing lifespans and he will likely shrug and say he doesn't care, as long as he can be around to witness them. But many of these same scientists working like alchemists towards immorality neglect ramifications such as overpopulation and depletion of the world's resources. Not to mention boredom. Because let's face it, after you reach, say, my father's age (he will soon be 77) you have pretty much seen it all. 

But before we discover our philosopher's stone, before we invent the elixir of life to keep us around forever, we will probably extend lifespans to, say, the triple digits without eradicating disease or aging, which specialists consider itself to be a disease, since aging is a result of a breakdown at the cellular level. Fix the cell, be forever young. Until then, be prepared that should you be among the future individuals to live to see 150 (the longest lifespan to date is roughly 122 years) you will possibly be wearing Pampers for the better part of five decades if not longer. Unlike Uncle Rico, I hope we can afford them.

But it is more likely that you will die. And death and dying are difficult subjects to broach. Nobody seems to want to talk about his own mortality or even that of another. Because as Donne wrote, the death knell you hear when someone near and dear meets his end "tolls for thee." Whether it is this year or the next or in 2050, death will come for you. My father often thinks of his own death, more so now that he has been diagnosed with a condition (PCV) that has a median survival time of 20 years. Suddenly he has a projected end date. Not so fun for someone who views himself as invincible. But my father is also a hypochondriac. Actually it astounds me that he somehow managed to evade the diagnosis that's been waiting for him since his blood counts began to rise in 2012. But he distrusts medical doctors. This itself is a form of prejudice. He had a bad experience with my brother, whose cancer went undiagnosed until it was untreatable. Afterwards he swore of Western medicine, but the irony was that he paid for me to go to medical school. He didn't complain when I left medicine, but wants my advice on treatment for his condition, which I diagnosed. I am officially the most expensive physician alive. It cost $200,000 to get through medical school and the patients I have most effectively treated are my parents, at six-figures per.

But dad has requirements for exactly how he is to go. He wants it to be painless and sudden. No six-month-long wasting away period as with my brother. But he wants forewarning, so he can say his goodbyes. And he wants to be fully conscious, so he won't take morphine and no going in his sleep. Now no death that I know of meets all these criteria. Heart attacks hurt. Strokes may not take you out but you can be sure a CVA will leave you impaired. And cancer is often a protracted death involving many hospital visits or powerful pain meds or both. My dad is an impossible man. So a rare condition affecting 1 in 50,000 would seem to suit him.

Anyway I asked him whose death he admires. If you had to go shopping, whose way of going would you buy. Surely not Christ's. Three days is too long, and hanging on a cross with needles in your limbs and a crown of thorns much to painful. Even for all the glory, which comes too late. Ramana Maharshi, a Christ-like figure in his own right, died at 70 of a tumor in his elbow. But he went through several unsuccessful surgical procedures before drawing the line at amputation. The tumor spread and Maharshi passed, peaceful and emaciated, surrounded by his loving followers. You'd think this would suit my father, but he doesn't like the idea of surgery or cancer. In a bittersweet twist blood dyscrasias are among the few types of cancer without a tumor. The bone marrow just churns out red cells without itself getting enlarged. So he gets his cake (no surgery), he just can't eat it. Which is fine. He's watching his weight. But don't go calling what he has cancer, no sir. I tell him: Dad, cancer is defined as a mutation in the DNA which causes unregulated cell proliferation occurring autonomously and exceeding the body's physiological requirements. You condition qualifies. I don't go to the dentist asking them to fix the hole in my tooth. A cavity is a cavity. Cancer is cancer. Death is . . . you get it.

Why think about death anyway? The cosmic joke is that you spend time staving off the common killers (heart attack, stroke, cancer) only to be hit by a car, which nobody thinks will happen to them, even though motor vehicle crashes are a leading cause of death in America. Or like former child star Patty Duke, whose son Mackenzie I went to grade school with, you die of a ruptured intestine. Or like the comedian Gary Shandling are struck by a massive heart attack right as you are calling 911. Or like Elvis you die on the toilet while trying to squeeze one out. Better yet, like my aunt's second husband, Yorn, you nod off after a huge Thanksgiving dinner with family and friends, and never wake up. Which dad says might not be that bad. It definitely beats wearing Depends.

SO MANY WAYS TO SAY ASSHOLE

The word solipsism predates Christ and appears in the works of philosophers, psychiatrists and metaphysicians alike. Derived from Latin, the term is used to express the notion that the self is the only reality. In short, a solipsist believes that the self (ipse) alone (solus) is (ism). Originally used by the Greeks, who believed that nothing outside the mind exists, and even if the external world does exist it cannot be known objectively or communicated to others, the term was also used by Freud who posited that other minds are not known but only inferred to exist. Because others speak and act as you do, and you exist and think, it is not a stretch to believe they do too. Rather than that they just appear to, as in a dream. Because though the characters in your dream seem to move and behave of their own free will, as thinking, feeling beings with motives and desires of their own, they are really only figments of your own mind, and any appearance that they are autonomous is merely an illusion. Which is why you can maim and murder while asleep and when you awaken dismiss your actions by saying the one you slayed couldn't feel, because he doesn't really exist. In this respect your dream self differs little from a serial killer who after raping and killing numerous victims absolves himself with the belief that because he did not feel their pain it must be unreal. Is the serial killer crazy? Do others exist and have minds and wills, or is it only seemingly so? You can never be sure. You can never know another, get into his or her mind. However hard the lovers may try. But penetrating others can be fun, which justifies the penis. Just don't go killing anybody.

If you look around you, you will find that there are many solipsists in your midst, perhaps yourself included. Those who believe they are at the center of the universe, the sun that shines on everyone else, those lesser mortals who are merely planets in their orbit. People so egocentric that they believe others are merely ornaments or impediments to their own happiness. I find this type in Los Angeles all the time. Even certain members of my own family fit the bill. It reminds me of the words of Christ. When Jesus is told that his mother and brethren desired to see him, he answers that his mother and brethren "are these which hear the world of God, and DO it." I keep preaching, but nobody seems to listen, of if they listen, to really heed me. The philosopher Rene Descartes proved his own existence with the words "I think, therefore I am." The conventional solipsist living in LA says "I think, therefore I am everything." A related term is egoism, the philosophical notion that the self should be the goal of all action, and others be damned! The egoist then becomes the egotist who thinks and talks about himself exclusively, so caught up is he with his own sense of self-importance. If in addition to arrogance he is exploitative and jealous of others, he becomes a narcissist. There are so many ways to say asshole.

But in these definitions the self is taken to be the individual mind, the personal point of view. Eastern religions, which predate the Greek sophists, broadened the scope of the self to include all that is. This "everything" is sometimes referred to as God, sometimes as the universe, sometimes as the universal mind. There is Ishvara (the personal God; the supreme soul), Atman (God dwelling in the heart of the individual) and the universe, or external world. But do any of these really exist? What truly exists is with you wherever you go, always. That is what it is to be omnipresent. To be real in the absolute sense, rather than just relatively so. What fits this definition? Not the external world, which disappears when you go to sleep. Not some personal God, who is only present when you think of and pray to Him (or Her). Not even your own point of view, which subsides back into the Self when you lose consciousness. Even your individuality is external and as such its existence is in question. As in the dream, when you conjure up a body to carry you around the dream world, only to awaken and find it was all a figment of your mind. We must act as though our persons exist as do the persons of others. If not we neglect the maintenance of our bodies and can wind up in jail for crimes against the freedoms of our neighbors. Even in a dream, it sucks to be locked up.

But while taking it as a given that the external world of which our personalities are a part exists, we must also allow for the fact that none of it really does. That the only thing in existence is the awareness in which the external shines, the awareness in which the individual mind participates, along with the minds of others. You are characterized by two things. One is your desire to be happy. The other is your self-love. Simply, you want to be happy because you love yourself. And you must infer that others are the same. Others love themselves and wish for happiness of their own, and these twin traits are what carry us through life. The trick is to broaden your individual view to include your fellow beings, unreal though they may be, and to concern yourself also with their happiness. You cannot make another person happy. Believe me I've tried many times, always in vain. The most you can do with the malcontents of the world, and there are many, is to say with Dostoyevsky: "You are only unhappy because you do not know that you are happy." You can however expand your love of self to include love of Self, of all that is. 

In Dostoyevsky's novel The Possessed, the narrator is a minor character named Anton who serves as the author's eyes and ears, and by extension the reader's own. Anton is the author's mouthpiece. He weaves in and out of the other characters' lives and moves through all rungs of society, rubbing elbows with the elite and serving drinks to his neighbors. He possesses detailed knowledge of personal histories and also a bird's eye perspective that takes in the whole. In his dealings with others, Anton is sometimes insulted, sometimes praised, but mostly he keenly observes everything around him, and with irony and humor he takes it all in stride. The narrator is unruffled, which is to say Dostoyevsky is unruffled, because whatever the fate of this character is, it all happens in the mind of the author, by characters who are also the author's creations. You too can be the Anton of your own life, or for that matter author, narrator and observer of your own tale. Be it tragic, heroic or comedic, just please let it be entertaining. Because nobody wishes to be bored.

Live as if everyone including yourself is a figment of your own mind, your creation. See yourself as other and others as your self. Because everything that happens to you happens through and in your own consciousness. This is what it means to be master of your own fate. DO it.

Wednesday, March 30, 2016

ON TECHNOPHOBIA




A while ago in Indonesia taxi drivers made the capital city of Jakarta a grid-locked mess and brought business and pretty much everything else to a halt when protesters flooded the streets to denounce ride-hailing apps like Uber, which they say threaten their livelihoods. Demonstrators set fire to cars and harassed those drivers who didn't take part in the strike.

Their actions remind me of that week during my junior year in high school when the faculty went on strike and their positions were temporarily filled by subs - that is, all but my English course, which was taught by Ms. Merritt who refused to take part in the protest, one would think because she needed the money. My classmates liked to call Ms. Merritt a scab, and became so relentless in their jeers that they once brought her to tears. Kids can be cruel. Such a descriptive pejorative conjures the image of a solidified patch of blood that persistently clings to the viable tissue. Scabs. We've all had 'em. These dry, purplish and rough slabs of tissue, unsightly though they be, are integral to the healing process. Scabs protect the underlying flesh as it regenerates; yet after a time scabs prevent the wound from fully healing by inhibiting circulation and exposure to oxygen, which can lead to scarring. Which explains our penchant for plucking them off. Hurts so good. To apply the term to non-strikers is quite a stretch, although the concept of clinging to "the way things were" does seem to fit. Which is what Luddites do.


I did not learn about Luddites in high school. In fact I had never heard of them until I became one myself, probably in the last decade or so, when I discovered our shall we say like-mindedness. The Luddites were 19th-century English textile workers who like our taxi drivers protested against newly developed labor-saving technologies emerging at the start of the industrial age. Like the self-employed weavers of England in 1815, today's taxis drivers are up in arms about losing their jobs. These Neo-Luddites are a 21st century rendition of a historical phenomenon which likely dates back to the day cavemen began hunting with stones and spears rather than with their bare hands. Shaping tools made our brains bigger, at the expense of our brawn. And now we are so many pasty, flabby wonks and techno-geeks. Nerds rule the world, all the more so if they are black and female. We love to root for the underdog and champion a cause. And it is rather fitting that the latest rendition should emerge in 2016, since it is the 200 years that the term Luddite was coined - it is believed after a man who took part in the protests. I have no interest in protesting or in smashing things, like Ned Ludd, or setting fires to cars, though this sounds fun or at least looks cool when it happens in movies that I do not watch. I don't like toying with technology so much as talking about technophobia.


I am not a technophobe, because I fear nothing. But I am shall we say wary. I have managed to avoid many trappings of the digital age, almost all of which center around the smartphone. If you don't have a smartphone, then you don't use apps like Bumble and Tinder and Snapchat and WhatsApp, and chances are you spend a lot less time than your connected peers do on social media sites like Facebook, Twitter, Instagram and Pinterest. Or no time at all, like me. When you check your phone zero times per day rather than 46 times per day, which is the American average, you really appreciate how many minutes there are in an hour. Without so many distractions vying for your attention, time is suddenly on your side. 




I'm not against technology per se. Like our Luddites, I just don't trust it. And they were onto something. The large-scale factory jobs that replaced skilled labor forced workers into inhumane conditions and overpopulated cities, which became breeding grounds for bacteria. It is no coincidence that shortly after factories started to spring up in European cities, the first cholera epidemics followed. In 1852 a two-year outbreak swept through England and Wales, claiming over 50,000 lives. Uber may not add cars to the road, since you leave yours at home, but it does make for a more congested city, since you are now travelling with someone who has no business being there except to chauffeur you around. And that someone probably makes stops of his own. Of course you cannot drive or call Uber without a smartphone, which brings us back to the point.


Does the smartphone make life simpler by streamlining things, or just add to the (in this case digital) clutter? I left the hospital precisely when iPhones were becoming ubiquitous. This was in 2009, around the time Apple and her imitators revolutionized the way we communicate. Now every doctor carries a handheld device, and often checks it both within and without the examination room, during lunch, in conferences and while walking down the clinic corridor, as I have had the misfortune of observing, basically by running into them. Today I accompanied my dad for his annual check-up and the internist treating him left the room three times to answer his phone. He said it was his wife, but I don't know whether to believe him or to think that's some code for this call is more important than you are right now. Technology can make things run more smoothly or appear to. The doctor ordered an ultrasound of my father's ankle and two minutes later my dad gets a call from the first floor radiology lab asking to schedule his appointment. They didn't even know he was in the building. He was able to go down then and there. The left hand may not know what the right hand is doing, but as in this case sometimes they come together in a clap and the effect is pleasing. But I wondered whether the doctor might have simply sent dad down to radiology straightaway and have done away with the middle man. What if my father didn't have his phone on him? What if God forbid he didn't own a cellular phone at all?


I don't think it's possible to practice medicine without being tethered to technology. The same goes for many professions. I'm often the only person in the room without a phone. But if I do need to make a call, asking a friend to borrow hers is a lot easier than walking downstairs and outside to the nearest payphone. Is this a good thing? I know, payphones no longer exist. But I sometimes like to see the look on a person's face when I ask him where the nearest one is. Stuck in the 90s much? At least I don't wear a pager. Which many doctors still do, in addition to their phones. Can't escape the 90s I guess. Which is a good thing, if you're a Neo-Luddite. In the pre-Internet days people were a lot thinner. The obesity prevalence in 1988 was 23%. Now it's 35%. I blame the payphone's extinction.


I am not a phone person, but even I miss the payphone, with its grimy earpiece and penchant for stealing change. One of the final excuses to head outdoors while at work has bitten the dust, out the same door as cigarette breaks when both made way for the remote control. Imagine how much exercise you'd get if rather than check your smartphone 3 times an hour you skipped down three flights of stairs and ran into the sun to see whether the payphone was ringing. You may miss the call, but one thing is for sure: you'd have one helluva tan. I know, I know. But where you cry sun damage I scream vitamin D. Sun is the best source. Enjoy some rays before tanning goes the way of the pager. Now that is scary.

Monday, March 28, 2016

YOUR DESTINY IS NOT YOUR OWN




English is a lovely language, and not only because it was the first I learned to love. It may not be as phonetically pleasing as, say, French or Portuguese (itself the daughter of French and Spanish), nor does it apply a set of rigid and logical grammatical rules as these Romance languages do. But hey, it's not German, which is guttural and has as many exceptions as there are rules, and more of both than English. 

What English lacks in "just the right word" it appropriates from other languages. It even pilfers from the gutters of the Germane. Schadenfreude, which literally means harm-joy, refers to the pleasure a person derives from the misfortune of another. As when your friend gets shat on by my a pigeon and you crack up. This is a pleasure I've never felt, and I'm no goody-two-shoes, which is a phrase all our own. And neither do many native English-speakers (feel schadenfreude), otherwise we'd have our own word for such malice. It seems we are a lovely people. Because we do have many words and expressions for the word like, such as to take pleasure in, enjoy, find agreeable, and even dig and be into; but none of these conjures such a vivid image as the Spanish and Portuguese word for like, which is gostar. They say Eu gosto de voce, in Portuguese. Or: Tu me gustas, in Spanish. In the noun form, gosto means taste. As in o gosto nao se discute. There's no accounting for taste. Another way of saying love is blind. Which doesn't translate into Portuguese. But only in a foreign tongue can we like a person so much as to taste him or her, as you would a Belgian chocolate or a fine French wine, or in this case, a Brazilian beauty. Sexy, no? Or maybe something Hannibal Lecter would say to his client-not-to-be before he literally tasted the person. With some fava beans and a nice chianti, of course. 

Karma is another word snatched from another idiom, in this case Sanskrit. That we didn't have a precise word of our own, and still don't, though the word fate often stands in, indicates that the concept of past lives is foreign to English speakers if not to Westerners as a whole. But karma can also mean cause and effect, which our science says governs the universe, so perhaps we are not worlds apart after all. The word itself, as used by the Buddhists and the Hindus, and by some Christians and Jews, though perhaps only in secret, means "the sum of a person's actions in this and previous states of existence, viewed as deciding their fate in future existences." Which is quite verbose. Why use 21 words when you can use one, so karma it is. 

It is not the word, which I quite like, but the conventional meaning with which I take issue. And with me the many followers of Eastern religions who believe in cause and effect - in other words that one's present is the sum of past actions and the future of presents to come - and yet don't find the notion of past lives quite as convincing as the authors of their sacred texts. Who were you before you were born? Identity requires continuity and sameness. Thus the related word, identical. Something, a book or chair or person, is the same book or chair or person because it does not change over time. Its present self remains identical to yesterday's version. But unlike books or chairs, humans are ever changing. We are never identical to our former or future selves, not even from moment to moment. Thoughts flit through the mind as blood moves through the veins and air through the lungs. Cells are recycled and replenished. The individual is an identity never identical to itself. 

So, if I'm never precisely the same me as the me before and yet to come, why do I persist each day in calling myself Adam, as though I were ever the same guy? This is where continuity comes in. Because though I am always changing, I am always here to witness the changes. I can remember being the guy I was yesterday and the day before, and as the minutes have given way to hours and days have elapsed, I never for one second cease to be me. And though I may not know the guy I'll be tomorrow, one thing is for sure: whoever I'll be, I'll be there to witness me being me. 

Defining this me is the hard part, and a topic for another discussion. Or perhaps it is so easy to define me as simply consciousness that it warrants no discussion at all. As the Hindus say: "I am. I exist. I know it. And I am happy about it." Many major texts can be boiled down to just this. I am. I exist. I know it. And am happy to know that I exist. (Even when nursing a broken limb or stuck in traffic or getting over my latest breakup - because even when it sucks to be me, existence itself is so much fun.) It seems that the nursery rhymers have it right when they sing, "If you're happy and you know it, clap your hands." We all find ourselves putting our palms together, don't we. So though in many cases identity requires sameness over time, it is often merely the continuity that suffices. I think, therefore I am? Well, I can remember yesterday, therefore I was. 

But past lives lack such continuity. Not only was I a different person in my former life (presumably) with different family and friends, living some place else, with a different body and name and likes and dislikes, and with no memory of my present life as Adam because back then this life hadn't yet happened - not only was my identity completely different, but I cannot even remember being anybody other than this me, who is always changing. But at least has the same name, and circumstances and associations. Though as I watch relatives grow old and die, some of them prematurely, and know that the list of has-been-to-be's includes me, I wonder what it all ultimately means. But that's just me being sentimental.

So karma as applied to your life works fine and well, but don't try and tell me if I win the lottery that it is due to kind deeds performed in a prior incarnation. It is due to buying a ticket, playing the game and maybe a little dumb luck. But there is a way that karma transcends your individuality and at the same time includes you in it. The family tree has a karma, and your ancestors' desires and actions affect your own, even though you may not always be aware of it. Sometimes this is obvious, when say a child raised by two physician parents becomes a doctor himself, or seeing how overworked and unfulfilled they are decides to do anything but practice medicine. But sometimes the influence is more subtle. My maternal grandparents married early (both were 17) and had 3 children by the time they were 21. Their relationship was what you might call stormy. When they weren't making babies (and my grandmother says with a good measure of regret that in addition to giving birth to her three daughters she probably had about 6 abortions) they were making war. My grandfather was a "womanizer" who liked to go bowling with his buddies after work and occasionally would come home smelling like women's fragrance, with or without the phone number of the wearer in question securely in his jacket pocket - which my grandmother would find, and then they'd come to blows. My mom tells how my grandmother used to wait up for my grandfather, lying in ambush after having filed her nails to a point, the better to pounce on him. And then they'd have sex. "He used to beat me," she says. "He was mean." And of course: "He was the hottest lover I've ever seen."

They divorced after 17 years and one more child, another girl. Because it takes a high sperm count to produce boys, and after so many nightly pumps my grandfather just didn't have it in him. And in the over three decades since my grandfather's death - from heart disease when he was 52 - my grandmother's feelings have not cooled. She is still hypercritical of the man he was. He was vain to the point of being effeminate (as evidence of this she likes to cite that he used to pluck gray hairs from his chest - something I also do but won't tell her lest she judge me too for it). He had a bad temper and a penchant for throwing her around, when he wasn't banging her against the headboards of course. My grandmother is so like a girl I used to date, who I used to call a man-hater in her own right, though I've since learned not to name call. Unlike Isabella, who viewed me in much the same light as my grandmother held my grandfather. Jealous of my looks (or so I like to think), critical of my grooming habits (I'd tweeze my eyebrows, and for this she'd call me gay). Okay, maybe I took it too far by wearing eyeliner in her presence, but I'm not alone. An army of macho men who happen to also wear mascara have come before me and since - like Ozzy, and Johnny, and Alice and Billy Joe. Unlike these guys I have no musical ability, but I do have the pecs. And everybody knows that face paint makes your eyes really pop.

Had I stayed with Isa longer than our year long "thang" - and I think slang has to be better in English than in any other language, by the way - we'd have gotten pregnant, then married before the wedding to save face (as my grandparents did), and would probably have had a couple more in swift succession. Not abortions, because Isa had one before we met and vowed never to have one again. And after repopulating half of LA we'd most certainly have divorced. Because like my forebears, we just didn't get along. I "beat" her, though it was she who cut my upper lip. I was an incorrigible "flirt" whom she couldn't trust. As she saw it. As I saw it, I got a bad rap, just like my grandfather probably did. 

And though I didn't see my grandparents go at it, I learned from the old war stories. And perhaps it was also imprinted on my genes, with the warning: Get with a hot Latin number and then get away or else wind up like your grand-dad, dead before his time. The family karma runs deep, and there are many other instances of it, too numerous to list here, but perhaps one more personal life slice will suffice. On my father's side, his brother Jamiel married a Latin woman, had two kids, then had an affair and married his mistress, an Italian, with whom he sired additional kids. He was following in my father's footsteps, who did exactly that, and I'd have tread my uncle's tracks had I not had his history from which to learn. The trick in life is to study your ancestry and the life stories of relatives both near and distant, so that when it comes your time to burn through all that collective karma - the expectations of your elders, the conditioning, the tendencies that are not your own, but handed down, the hopes and the fears, and more than a few ups and downs between the sheets - you can do it without too many snags, nail marks or broken lips. And if you do less of it, you can expect to have boys, which was my father's dying wish. It won't live on in me, though it could have.

Because I have transcended my fate, or so I like to believe. And once you do yours, you stand alone, free to remake yourself, to be who you truly are. A child of the universe. And I am your proud and unbetrothed brother. And together we can make babies all our own.

Sunday, March 27, 2016

CALLING ALL MOMS



A recent (March, 2016) issue of Scientific American magazine showcased a study published in the British Medical Journal. The BMJ research evaluated inequality in American medicine. The researchers looked at the heads of over 1,000 departments of 50 top U.S. medical schools and found that, though for the past 15 years woman have made up nearly half of all U.S. medical students, and though fewer than 15 percent of men wear mustaches, medical school departments are significantly more likely to be run by a mustachioed man than by a woman

In fact the "overall moustache index," a ratio of women to mustaches, was found to be 0.72, meaning for every 10 department heads with facial hair, only 7 heads were women. The researchers concluded that the fairer sex is horribly underrepresented in medicine's highest ranks and urged medical institutions to "hire, retain, and promote more women." Political correctness in its most flagrant form.

But the study ignored one important point. Maybe fewer women than men (and even mustacheioed men) run top medical programs not because they cannot but because they do not wish to. Ever think of that, BMJ? After all there is a certain extracurricular activity called child-birth and -rearing which occupies a crap-load of time and which men cannot list on their resumes (for obvious biological reasons). This hallowed practice requires at least 3/4 of a year, and up to 3 years if you breastfeed for the recommended length of time. Three years of undivided attention. A fast marathon requires only three hours of such effort, and less than one percent of the American population has completed one. Because like competitive running, raising a child is a job in itself. In other words it's hella tough!

Such research is like evaluating the number of men who practice rocket science or other avocation and are also the heads of major institutions. That number would likely be zero, unless you call fantasy football a part-time gig. There is not enough time in the day to be an optimal caregiver and a career person as well, not if you want to do both well. And women who are more practical and intuitive if not wiser than men, may be sensitive to the drawbacks inherent in certain lines of work, medical careers among them. These drawbacks include too much paperwork, not enough pay, or too much pay for not enough work, if you're like the CEO who conducts his business over drinks on the links. Which leads to guilt, an emotion too few men feel to care. Which is why most CEOs are men.

Furthermore, the female ego may not need the gratification that comes with such a title as "program director" or "medical chief." Until we raise an outcry about why so few men give birth to children, we should not cry gender discrimination. Rather, let's allow biological forces to match personality with perfect job. Because, really, that's what's been happening since the first male and female mated.

As it is, women represent almost half of the U.S. workforce and hold 51% of high-paying management and professional positions, according to the Bureau of Labor Statistics (BLS). There are more women accountants and auditors, financial managers, insurance underwriters, medical scientists, education administrators, tax collectors, veterinarians, psychologists and elementary and middle school teachers. By lobbying for equality in the workplace defined as "equal representation across jobs" women are forced out of the home into jobs they may not be suited for or wish to do, at the expense of the relationships they have been so assiduously nurturing with their children and spouses. Because let's face it, in relationships women do most of the work.

As a result, kids are raised by strangers, and husbands are left eating Hungry Man dinners and drinking Pabst on the sofa alone - which they call a couch, and never bother to clean up the crumbs that fall between the cushions. Women too suffer from this self-imposed domestic estrangement. For who can ever take the place of the inveterate nurturer? Men have traditionally been the providers, which doesn't mean that they cannot also cuddle and coddle, only that males are not as perfectly suited to the task. How can a man possibly develop as secure a bond with his child as the mother who carried and breast-fed that child, which is literally an extension of her, and who by a feminine instinct more powerful than anything in a man's repertoire, is uniquely attuned to her child's needs?

It's like asking mom, who is a math whiz, to coach her son's Little League baseball team when she has no knowledge of the sport while dad, who played college baseball and is a veritable encyclopedia of knowledge and experience on the subject, and who flunked out of math, tutors his other son in Algebra. Sure each can do what they are not perfectly suited to, but not nearly as well as the other. If you're looking for comic relief, such a set-up provides it in spades. Which is why I laugh every time I see a man with a baby slung around his belly. Though if you've got stock options on such slings, I'm buying. Unless things go back to normal, which I hope they do.

By normal I mean this: What we need to understand is that raising a child is the most difficult, necessary, rewarding and thankless job under the sun. Children are our future. Sound familiar? It should, because Whitney Houston sang the line in her hit, "The Greatest Love of All." So teach them well and let them lead the way, show them all the beauty they possess inside. Give them a sense of pride to make it easier, let the children's laughter remind us how we used to be. Right?

The world's fate is determined by the actions of the humans on it, and our actions are functions of our consciousness, which is influenced by our upbringing. No teacher, tutor, maid, au pair, day-care slave or babysitter can give your child as valuable an education as you can. Nor can your husband. So rather than outsource the task to some stranger or your lesser half, do it yourself. It's one of the things women were put on this earth to do. And that's not some slight. The fact that you have been gifted the ability to shape our future by cultivating the minds of those individuals who will inhabit posterity is proof of your superiority. Because the job is awesome. You are not some second-class citizen but shaper of the race, CEO of our destiny. I'd take that over head of Merck any day. 

What really is thankless and almost worthless is the office job held by most providers, many of them traditionally male. A sedentary existence pushing paper and staring at screens to earn money by making more of it for one's boss without building anything or producing tangible results (as in, say, a child who lives and breathes and says "Mommy you're my universe!"). Leave such grunt work to lesser individuals, ie males. Women, focus on our children. The world needs you. Plus, you get to stay at home, and from one homebody to another, is there any place you'd rather be? Where else than your own domicile do you have such easy access to those twin essentials, the kitchen and the bathroom? A stay-at-home mom's life is a writer's dream I guess. Live it.

Saturday, March 26, 2016

IF CHRIST WERE ALIVE TODAY



Last week Tyler Perry presented The Passion, an American television special broadcast by Fox from New Orleans and retelling the final days of Christ to music. When interviewed by Time Magazine Perry said he believed that if Jesus were alive today, rather than travel from village to village on foot to get his message across, he'd go online and "make use of all these tools." Would he? I have for a long time maintained that if Christ had a website and charged by the hour he would no longer be Christ. Christ was a humanitarian. Charging a fee for services would make him just like the very Pharisees he rebuked for making the temple a place of business. It was that people came to Christ for help, the suffering, the blind, the sick and the needy, and that he helped them without asking anything in return but that they leave everything and follow him (which few did) that truly made him a Savior of humanity. 

There are hundreds if not thousands of so-called saviors today - TV evangelists, self-help gurus, life coaches and the like - who invoke Christ's name as they emphatically dispense advice, provided of course that you part with your hard-earned cash. Christ was a carpenter who lived simply. Unlike the Tony Robbinses of today, he didn't have a yacht and several wives, nor would he if yachts were fashionable and feasible in his time. And surely he didn't have Robbins' $500 million, or the equivalent 1st century AD sum. Yes Christ did speak of higher things, communicating to anybody who would listen a message which to that day in those parts was unheard of, revolutionary, and yet universal and simple. Love God, love your neighbor, love your enemy. 


Now holier-than-thou preachers use these slogans to line their own pockets. If Christ didn't ascend into heaven as the Christians believe then he is rolling over in his grave. And if Jesus did walk the earth today surely he'd chastise these charlatans for their paper-thin message. There are those who talk the talk and those who walk the walk. Few are they who like Christ can do both. Granted we don't know exactly what Christ was doing between the ages of 13 and 30 but it was likely more walking and talking. If JC walked the earth today I think he'd be strutting it off the grid. He'd certainly shun the big cities, divorced as they are from nature, in favor of a quieter, simpler existence in communion with nature. For he liked to speak of the birds and the bees, and not the way you're thinking, saying "Look at the birds of the air; they do not sow or reap or store away in barns, and yet your heavenly Father feeds them." 


He'd enjoy a solitary existence in some Alaskan cabin perhaps, or if compelled by circumstances to rub elbows with urbanites, maybe he'd be a plumber, and the coolest one around. He'd probably spend his time doing something simple, yet skillful and practical. And the few seekers who needed to find him, be they in some remote part of the wilderness or simply with a clogged drain, would get their wish. And it would be these humble and fortunate individuals who'd spread Christ's message, possibly via the Internet, as Perry believes, or possibly just by travelling over land and sea as Christ's successors after his bodily death.




Or maybe Christ is alive today. And not just because his name is on the tip of every person's tongue, though usually only when he or she is frustrated enough to exclaim "for Chrissakes" or "Jesus H. Christ on a Popsicle stick!". Maybe his spirit lives on wherever his message is practiced. That's what I choose to believe. And I don't need a website to tell you this, and you read these words for free. I'm just here to help. But don't call on me to fix your toilet, because I'm no good at that stuff. Personally, I nominate Zach Galifianakis, who looks a bit Messiah-like. Sure he lacks the Savior's slimness but he makes up for it with a sense of humor, which if serious Jesus had more of maybe the Passion never would have happened. Imagine such a world...



Friday, March 25, 2016

THANKS FOR READING



Reading has fallen out of favor. I mean the kind that requires more than 140 characters, which is the limit for Tweets. But even Twitter is no stranger to hard times, having lost over $2 billion since launching over a decade ago. Proving that there are loads of us eager to express ourselves, just nobody around to hear what we have to say. The art of listening has fallen into decay. And it's made even President Obama worried. He recently asked the novelist Marilynne Robinson about the cultural impacts of the decline in reading. Obama declares that most of what he's learned in life - the stuff of importance, such as empathy, and ambiguity, the search for truth and the ability to connect with those who are different than oneself - has come from novels. I don't know which books Obama is referring to, but I doubt he's reading much of what's out there today.

Because the current deluge of self-absorbed novels, such as those by the Norwegian Knausgaard, who by the way has great hair, reflects our world-wide tendency, facilitated by social medias and selfies, to collectively contemplate our noses. In other words the novels are written by authors locked in their minds about characters locked in their minds for readers locked in their minds. Goodness knows how the few readers that do read today's self-conscious self-exposure fiction can be coaxed to take time away from their own personal lives. It's surely not the writing style of these works, which is jumpy, jagged and digressive. No Jane Austen here. Instead of that great author's Pride and Prejudice, we are reading Pride and Prejudice and Zombies, if that's any consolation. That is when we're not taking selfies and photographing our food.

Okay, so we are all celebrities, at least in our own minds, and not just the younger, "Me" generation. Knausgaard is older than me. Wait, the Me generation actually refers to the Baby Boomers, so at nearly fifty Knausgaard fits right in. The younger generation is just better at Tweets. But does the tree falling in an uninhabited forest make a sound? Some would argue no, not if nobody hears it. If the only person who reads your Tweets is you, just like the only person who reads my words is me, is there even a point to writing them? I believe there is, or else you wouldn't be reading this. I forgot, you aren't anyway. But even though you aren't, my words still exist. They are my way to play at being creative, engage in self-expression, use words like indubitably for no reason other than it sounds funny and because I can.

I still read books, both fiction and non. And while I have recently been seduced by the fact-based, statistics heavy work of writers treating 21st century concerns like factory farming and fathering, a novel is always bedside, if only on my Kindle. Which I think is out of batteries. It's been a while. The last novel I read was Dostoevsky's Demons. Though it was written in the 1800s and set in Russia, I could relate to most every phrase on every page, many of which had me in stitches. I don't know that humor was the author's intention. Besides, it was free. Lucky me. 

And when I look back at my life's most trying times, it was always a novel that got me through. When my first girlfriend and I broke up junior year of high school, I had been reading Mark Twain's Huck Finn. It was assigned reading for English class, and I got so swept away in the character's picaresque adventures I forgot about my heartache. In one scene Finn, who is on the run, dresses up like a girl, and when he is harassed by someone in the particular town he happens to be passing through, he pleads, "Please to not poke fun at a poor girl like me." This line had me rolling for reasons I still cannot fully explain. A few years later a string of personal tragedies, including my brother's death, my parent's separation and more romantic turmoil, I happened to get my hands on Voltaire's Candide. This slim volume, about a naive young man who refuses to dispense with the notion taught him by his philosopher/mentor that "the world we live in is the best of all possible worlds" proceeds to undergo the most severe hardships I had ever read about. The particular ordeals escape my recollection. Something about being stranded at sea, sold into slavery, flogged. In any event Candide's misadventures made my own pale by comparison, and once again had me ruddy with merriment. And the ending was a happy one. When it came I found myself wishing the tale were longer than 120 pages. 

In answer to my prayer, destiny dropped the 800-plus page novel Don Quixote into my lap not a month later, and Cervantes' ornate prose wove a spell that transfixed me to the page. I couldn't tear myself away for longer than it took to down a beer, and then I was back to reading. Despite the ridiculous situations he finds himself incessantly in, Quixote himself is one of the most sober characters in fiction, a philosopher through and through. So following his example I drank a little less, though not so little as to lose my precious buzz. After all at fifty plus he was twice my age, and I still had some living to do. There have been other books that have transported me to a world that is so bizarre as to rid my mind of any cares of its own, and to leave me glowing with contentment, not unlike what one feels after some good sex.

The novels of today are about the very mind, preoccupied and obsessive, that I am trying to escape in reading them. So either I can reread these classics, which I almost never do since I'm not one for encores (ask my former sweethearts) or else I can write something as funny and witty myself. Which is no easy task. Cervantes' classic just turned 400 years young, and it has yet to be outdone. Besides, these days my patience only endures for thousand-word bursts, which is where we're at right about now. Until next time, thanks for reading. Or not, as the case may be.

BLACK LIKE ME


The off-Broadway play Hamilton, which sets the life of founding father Alexander Hamilton to music, is all the rage today. But the real story is about William (1797-1850), who was Hamilton's illegitimate son. In the words of more than one female, he was also "super hot." When he was not turning heads with his wavy hair and well-formed features, Junior was pounding nails as a carpenter. When he wasn't practicing carpentry, he was lobbying for the abolition of slavery. In the early 1830s he participated in the first national conventions of African Americans and was an outspoken opponent of racism, often risking life and limb to go against the grain - that is, against the lining of wealthy landowners' pocketbooks, or whatever men used to keep money in back then. I give up.

When asked about racial equality, Hamilton replied that any difference between blacks and whites "is in favor of the people of color." That's leaving no room for doubt about who's superior. And truly blacks have a leg up on whites in many a sense. Blacks are better athletes in almost every sport they're interested in, not just America's big three - baseball, basketball and football - but also soccer and golf. And tennis, where the Williams sisters can't be beat. There are fewer persons of color among the stand-outs in hockey and bowling and triathlon because these sports offer little in the way of either money or glory. Which is also a testament to the brothers' high IQ. It was after all a black guy who said "Show me the money" (Cuba Gooding, Jr; Jerry Maguire), although a white guy did write the line. While it is true that in bodybuilding, which showcases the most sculpted and symmetrical bodies under the sun, there have been the Arnolds and the Dorians, both of whom were white, neither American, the perennial winners are often men of color. I'm talking Lee Haney and Ronnie Coleman and the current champion, Phil Heath. Blacks also excel in the ring, whether as UFC fighters or boxers. The top three pugilists on anybody's list are Ali, Tyson and Mayweather, all with similar skin tones. It's the ones watching these stars, rooting for them, betting on them, making money off them, who are white. But not always, Don King. And the fighter makes money too. Mayweather's last payout was $210 million, so who is punch drunk?

Even in white-dominated sports like bobsledding, let a brother in the game and he dominates, as did Herschel Walker who competed in the Olympics, and in football, and in the UFC. Damn son! Every two-sport athlete I can think of - Jackson, Jordan and Sanders come to mind - have been black, as are the funniest men on earth (Murphy, Pryor, Chappelle ). And forget about musical chops. Who is as astronomically talented and multifaceted as Prince or Michael Jackson, either before or since? You see white boys rocking out to the music of these dark-skinned demigods and their gold-teethed rapper counterparts all the time. How many black kids try to be white? Other than the twin kings of pop, who lightened their skin and may have narrowed their noses, what do you think? 



I'm convinced Elvis had black blood, too. Which is what my friends' parents used to say about me, not just due to my naturally dark skin, which is courtesy of Lebanese and Mexican forebears. Mostly it is because I grew up playing sports with inner city kids, racing as fast as I could, being one of them because they let me. In class we formed a Jackson tribute group and belted out Beat It while thrusting our pelvises. And as the black kid they let me be, I take especial pride in boasting that blacks are in general more shall we say endowed than whites. I have not seen many penises other than my own and those of my immediate male relatives, but if pornos and the gossip of girlfriends are any indication, then this stereotype is justified, as are the sayings "black is beautiful" and "once you go black you never go back."

I wouldn't know. I've never gone. And blacks aren't to be underestimated when it comes to smarts. The physicist to the stars, Neil deGrasse Tyson, is black. And so is the president, who is also a scholar and a Renaissance man, unless you are like Trump and believe he's an Arab. But Trump is a philistine, if we're trading terms. In fact we blacks are so smart you don't find us doing jobs that are just no fun to perform, even at the risk of being called lazy. I had a friend in high school named Lou Black. His mother was an albino and his father an African, so Lou had the wiry hair of one and the translucent skin of the other. But he was insistent on being called black, and not just in name. "I'm Black!" he'd yell whenever we commented on how sensitive his skin was to the sun. We didn't push it. Lou was big in more ways than one.

Which is why I don't get it when members of our race cry persecution. How can superiors be persecuted by those who natural selection has placed at their feet? Maybe it's just a legacy of slavery and yet another indication of how backwards our world can be. Some of the most brilliant thinkers history has ever known renounced their positions and took up the staff and begging bowl when the dullards above them who called themselves kings lorded it over everyone else. Buddha was one of these cats. He gave up his kingship to live the life of a vagrant. And one of the world's biggest religions emerged in his name. Who's king now? Like Christ. Think of the money the son of God could have made had he directed his supernatural talents to monetary pursuits. Instead he moseyed around bearded and barefoot, the world's first hippie. And they called him the King of the Jews. Can't escape your fate.

It's the same for women, who cry out for equal rights and pay and the like. Women are without a doubt the stronger sex. Who else could endure the agony of childbirth? Or the slobs that men can be? And a woman's intuition trounces man's logic any day of the week, while the maternal instinct is what makes the world go round. It's enough to make me almost wish I had a pussy. But not quite, because then I couldn't mate with one, which has always been my favorite sport. But if I were as busty as I am black, or rather more, I'd be the next Oprah. I'd let the small sickly inferior race pretend at superiority while they showed me the money. And on the way to the bank I'd say, We know who's the real winner now, don't we? As it is I am neither woman nor winner. But like my man Hamilton I do have wavy hair.

FISH OUT OF WATER


I once had a friend who suffered panic attacks. Bouts of intense fear and trepidation would seize her unawares and without warning. These episodes were replete with all the usual symptoms: heart palpitations, sweaty palms, trembling, choking, chest pain and shortness of breath. During these attacks she'd always believe she was dying or going crazy, or both. My friend also developed agoraphobia, which is seen in a third of individuals with panic disorder and involves fear of open spaces from which it is difficult to escape, like shopping malls and arenas. To make matters worse, she'd often experience sleep terrors, where she'd awaken in the middle of the night in the grips of intense fear, not knowing where she was, and incapable of being soothed, only to forget about it the following morning. 

Said friend didn't have any organic cause for panic attacks, which can mimic the effects of heart disease, thyroid dysfunction, anemia, asthma and other conditions. So I suggested she give up eating meat. It is well known that when animals are slaughtered their adrenal glands release stress hormones into the blood. Adrenaline and cortisol flood their system and are concentrated in the meat, which unwitting consumers then eat. Since all the symptoms of a panic attack can be brought on by adrenal hormones and are regulated by these hormones, I argued that if she curtailed her intake of this exogenous source of stress her system would cool down and we could once again go to Angels games. 

Because I'm no stranger to panic-like symptoms. One summer I was visited by an intense dread of drowning every time I'd jump into the pool. When submerged I imagined myself without means of egress and would quickly grope for the water's surface. It made for a not-so-fun time. That summer I was eating sushi a couple times a week. Were the stress hormones in the fish to blame? In part. But also something which science has yet to develop the sensitivity to trace. Imagine if you will our little fish swimming about in its natural habitat only to be swooped out of the water and left to flounder and flop to its death on the boat's deck. Or if you're like the deep-sea fisherman I once went on an excursion with, you lock the fish in a cabin beneath the deck and wait for it to stop thrashing about. Try to fathom the fear the fish must be going through in those final moments of life. I can. Because this fear was transmitted to me through the meat, and I was fearing for my life not on land as the fish but in the water, which is not my natural habitat. 

So I gave up sushi, and the fears went away. Was there a psychosomatic component to my self-prescribed remedy? Perhaps. As of yet, we can't be sure. Is giving up meat the cure for night terrors? I don't know. My friend never took my advice. Rather than give up grilled chicken, she went on an antidepressant. It killed her sex drive, which killed our friendship with benefits. Bummer. But if you suffer from panic attacks, anxiety or outright sleep disorders and you persist in your yen for dead flesh, try giving it up. Your dread just may abate. Your sex drive too, since you won't be taking in as many sex hormones, but only a little. You'll still be able to get it up, unlike with Prozac. Or so I've heard.

Thursday, March 24, 2016

WHAT MAKES US HUMAN?


What is it that makes us human? What separates you and me from the rest of the animal kingdom? Is it our opposable thumbs? Our capacity to love (and to hate)? Our brutality and bellicosity? Ask this question of the next person you meet on the street. If he has given a little thought to the matter (and maybe read the same books as me) he will likely say the twin capacities of reason and reflection are what most distinguish us from our beastly cousins.

That is, to think deeply or carefully about something (reflect), especially past events in order to learn from experiences and avoid future mistakes. Which is why we study history. It is also the essence of wisdom. And to reason is to use logic in order to problem solve, whether about what to have for dinner or merely to contemplate the nature of the universe. The latter is abstract reasoning, the territory of philosophers, physicists and the street corner crazy person, whereas food is just fun to think about. 

But when it comes to reason and reflection animals are often underestimated. Anyone who has ever owned a pet knows that they learn from past experiences. I've thrown my dog in the pool a couple times, just to watch him dog paddle, and now he knows not to get too close to the water. Unless of course it's a really hot day, in which case he doesn't mind taking a dip, provided that after drying off he gets a treat. That's reflection at work. And scientists put rats through mazes all the time. We watch them scurry after food or evade the electric cage to showcase their problem solving abilities, while engaging in a little bit of animal torture. Are these experiments inhumane? To justify such treatment we say it's a dog eat dog world. We are more like our pets after all. And we thought we were special!

But we are. Which is why I hereby nominate two other characteristics which, unlike logic and learning from our mistakes, are unique to homo sapiens. I mean suicide and masturbation, because I'm pretty sure no species of animal other than our own kills itself or makes itself come. I do not include the bees who dive into the swimming pool in the heat of summer and wind up belly up in the filter. They're just trying to cool off and didn't reason their actions out. Nor do I count as suicides those little buzzers who have lost their stingers and know that they are dying already, only slowly, so in an effort to hasten their demise crawl over the ledge into the chlorine. They do this over and over again, despite my efforts to save them. Nor do I include in our select group the pooch that humps its owner's leg until the friction of penis to belly causes inadvertent ejaculation. I don't think simply getting its rocks off was the animal's aim, though maybe it was. I can't enter the canine's mind. When I want to masturbate, I position myself with some oil and a tissue or two, preferably alone and in the dark. Just me and my disposable thumbs. I don't mount my neighbor. Which if you ask me bespeaks a desire to spread one's seed, or it's just being cocky. But while animals don't intentionally off themselves or for that matter get their rocks off, humans do both all the time. Not just your average Joe, but philosophers and famous people, too. Perhaps more than most.

Take Sigmund Freud, who with his psychoanalysis and writings exhaustively demonstrated the powers of reason and reflection both in himself and in his patients. Freud, who used cocaine, was also a long-time tobacco smoker, which is a form of slow suicide. Indeed he was diagnosed with cancer of the mouth, surely due to the several cigars per day habit he developed in his twenties. The doctors who treated Freud concealed the severity of his condition for fear that the shrink might despair and take his own life. He didn't kill himself, and wound up living with his condition for over a decade. He did however continue to smoke cigars against his physician's advice. He was hooked on tobacco, believing it enhanced his productivity. In fact Freud told one colleague that all addictions were merely substitutes for masturbation, "the one great habit." 

It seems reasonable to conclude from this that as with suicide, Freud was no stranger to spanking the monkey. Or choking the chicken and beating the meat, though these and other euphemisms bandied back and forth by high school boys everywhere these days were unheard of during the doctor's time. But I think it is true that addictions are all forms of masturbation. As with masturbation, smokers, drinkers and gamblers alike can gratify their urges alone, though to achieve fulfillment without a partner, the sex addict must get creative, as in by cutting out cantaloupes, or else making use of porn. 

And I think suicide, which is already the 10th leading cause of death in the U.S. and on the rise, would disappear altogether if the would-be self-murderer just "busted a nut" before committing the act. (Ladies you'll have to excuse me, I don't know of a catchy phrase for a female orgasm. If you do, please share. I'll be in my bedroom - with oil.) Because most guys just fall asleep after said nut has been busted. The suicide-to-be probably would too, and awaken to a new outlook if not a new day. 

Just don't try masturbation and suffocation at the same time. This is known as auto-erotic asphyxiation, which purportedly did in INXS lead singer, Michael Hutchence, and self-titled martial arts evangelist David Carradine. Proving what I've always believed: that it's not wise to attempt two things at once, whether reasoning or rubbing one out. Because you'll do neither one very well and you might wind up dead.

Monday, March 14, 2016

HOW THE ZEBRA GOT ITS STRIPES


Recently I crossed paths with a dear friend. When I asked after his health, he wove a tale of woe. He had suffered repeated ankle sprains, twice in as many years. The man is, in his mid-70s, at an age when the tendons become more lax. His largely sedentary existence has caused a smidgen of weight gain especially around the middle, which puts an extra strain on the ankles. I asked him how he had twisted his ankle. Was it playing Frisbee with his dog, or perhaps hiking with his wife? 

"Funny thing is, I don't remember injuring my ankles at all. I just woke up one morning and could hardly walk."

"Did you say ankles, as in plural?" 

"Yes, first my right, and then my left. I am just now finally getting over the left sprain."

"How do you know it was a sprain?

"The MRI said mild sprain."

"How long did it take you to recover from these sprains?"

"About eight weeks. I could hardly drive my car when the left one was out. The clutch was just too stiff. I've been Ubering all around town."

"Lucky Uber. You mean to tell me you were out eight weeks with a mild sprain?"

"Hmmm, hmm," he said, nodding his head. "Ten weeks the second time. It's week 11 and I only started driving again last Friday."

"No break."

"Nope."

"Hmmm..."

He told me his ankle had been red and swollen and tender to touch. Had he been suffering any other symptoms, like weakness, fatigue, morning stiffness? He shook his head. "Only thing is when I get out of the shower my skin itches a bit. And you know how I've always had reflux? It's been getting worse." He gave a rueful shake of his head. "I'm just bracing for the next time my ankle goes out. Could be any day, for all I know. Third time will definitely not be a charm."

Back to back ankle sprains separated in time by a year and involving both feet, without any frank insult, and with symptoms out of proportion to radiographic findings. This did not sound like an ankle sprain to me. I wondered if he had suffered a blood clot in one or both of his legs. A desk job such as my attorney friend's can predispose to the development of thrombi, particularly in the lower extremities. With no way back to the heart, blood pools around the ankles and can be very painful, even so far as to mimic the effects of an ankle sprain. 

"They tested for a DVT," my friend told me. "Negative."

My thought at this point was arthritis. There are various types. Rheumatoid arthritis is a systemic disease with an autoimmune component that usually involves multiple joints, especially of the hand, and these patients characteristically present with morning stiffness. Gouty arthritis often involves one joint, especially the first toe, which becomes red, hot, and swollen, but it can occur in the ankle and jump joints.

"How can I have gout," said my friend, "when I don't eat gouty foods?"

By gouty foods he meant foods high in purines, particularly meats and seafood. The purine content of food reflects its nucleoprotein content and turnover. Foods containing many nuclei (like organ meats) have many purines, but rapidly growing foods such as asparagus, spinach, cauliflower, mushrooms, as well as beans, peas, and lentils, and of course yeast-containing foods such as bread, which my friend loves, are also high in purines. I let this slide for a moment. A simple blood test can detect rheumatoid arthritis with a high degree of reliability, but to diagnose gout, and its sister by another mister illness, pseudogout, requires sticking a needle in the joint, and my friend dislikes needles. 

But my friend had no history of gout, and since his diet has been the same for most of his life, which is all of mine, I doubt that new-onset gout was due to food, or if he had gout at all. But a more complicated picture was beginning to present itself. Newish onset of arthritic pain in both ankles, with vascular changes suggestive of a circulatory disorder (the thrombosis was ruled out, but my friend complained of increased swelling with positional changes) plus itchy skin on exiting the shower, which was also new. 

I asked to see his legs. He pulled up his pant leg and pulled down his socks. Sure enough he had no hair around his ankles. His leg hair, which was generous, abruptly stopped mid calf. Hair loss in a sock-like distribution is suggestive of atherosclerotic changes in the small vessels supplying the leg and foot. I had learned in medical school that this finding, along with a patient's complaint of claudication, or pain in the calves on walking which is relieved by rest, is a harbinger of cardiovascular disease. Claudication is like angina, or chest pain, only it affects the legs. But my friend told me that like his father he's had no hair on his legs since he was in his twenties. So if this was an indication of atherosclerosis, it was long-standing and likely not the cause of his circulatory disorder. So what was, and how did ankle swelling relate to his ankle pain?

I asked if he had had any blood work done recently. He showed me lab tests from the previous two years. I looked at his CBC, or complete blood count, and a slew of abnormal values jumped off the page. His white cell count, platelet count, and red cell count were all elevated in 2014. Without symptoms, I could understand if such a finding were overlooked or chalked up to the effects of dehydration (or what doctors refer to as hemoconcentration). In 2015 his platelet count had fallen back to normal, but his white count and red cell count were still quite high. Had he been fighting a chronic infection? If so, then why was his red count getting even higher? This can sometimes be seen at high altitude, when the body responds to rarefied air by producing more oxygen-carrying erythrocytes (red blood cells). But my friend lives at sea level. So why was his hematocrit (percentage of red blood cells in blood) greater than 60% when anything above 50% is abnormal? 

Elevation of several blood cell lines screams one thing: blood dyscrasia. Or to use a more familiar if also more intimidating term, leukemia, which is a form of cancer. It is strange that the condition should present with ankle pain. This is what on the wards we'd call a zebra. In a world of horses (ankle sprain being the most common cause of ankle pain, just as horses are more common than zebras) zebras often get missed. And this particular zebra has a medical name all its own. 

Polycythemia vera is an acquired myeloproliferative disorder that causes overproduction of all three blood cell lines (red, white, and platelets), most prominently the red blood cells. It is distinguished from other blood dyscrasias by the elevated hematocrit, since most leukemias typically affect white counts only. With PCV as with other leukemias, patients typically complain of headache, dizziness, blurred vision and fatigue. My friend was spared these symptoms. But another common finding is pruritus, or itchiness following exposure to warm water, which is believed to be attributable to histamine release from extra basophils, a type of white blood cell. Histamine can also contribute to peptic ulcer disease, which is also more common in PCV sufferers.

The condition occurs at around 60 years, in more men than women. And the biggest complications are, paradoxically, both bleeding and blood clots. Too many red blood cells can bleed out, or get lodged in vessels and cause a blockage. In fact sudden death from heart attack or stroke has been known to occur without prompt treatment. PCV is caused by a genetic mutation that is likely environmental, meaning exposure to ionizing radiation or chemicals in food rather than something that is inherited from one's parents. Which is a relief to me, since the friend in question is (true confession) my father, and I have taken the license of dramatizing the story somewhat for effect.

A blood dyscrasia can be easily overlooked as a zebra in a world full of horses, but PCV explains all three abnormalities seen in my father: viz, the elevated hematocrit that is its hallmark feature; the circulatory problems due to highly viscous blood; and even the ankle pain that masqueraded as a sprain and which was in reality gout. Because an unchecked proliferation of blood cells is counteracted by their rapid destruction, which floods the blood with the very purines my father said he doesn't eat. The uric acid that is formed precipitates in the joint space in the form of crystals, and these crystals cause the characteristic pain and immobility of arthritis, which unlike a mild ankle sprain, can persist for months without treatment, as it did in my father.

So what is the treatment for PCV? Phlebotomy. Patients need to get regular blood draws (500 ml removed per week) to lower hematocrit, which reduces the risk of clot, and also lowers the uric acid levels, minimizing the likelihood of a gouty recurrence. A diet low in iron will also discourage the production of excessive red blood cells. Drugs may not even be needed to manage the disease, which has a median survival of 20 years. But if so, hydroxyurea is on hand.

Only about 5% of cases progress to acute leukemia, which itself is becoming increasingly more treatable. Where once patients could only hope for 3 or so years, new agents have doubled the extended lifespan, and the prognosis is continuing to rapidly improve as new therapies emerge. 

But first, phlebotomies. So dad, get used to needles.